DICOM,the Enterprise,and Digital Pathology

David Clunie (dclunie@dclunie.com)Pixelmed Publishing, LLC.

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Enterprise Image Repository, Interface EngineModality Worklist Services

Standards-based Communications (DICOM, Web Services, …)

Standards-based Communications (DICOM, HL7, Web Services, …)

Digital Capture Systems

DICOM Wrap or XDS Import Software

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Group #1Native DICOM Image Sources

Group # 2Endoscopes,Microscopes,

In-room Cameras

Group # 3Photography,Video Clips,

Mobile Apps, APIs

Group # 4Image Exchange

Inputs and Outputs

Othe

rs…

. Gateways

EHR

Imaging ProcedureOrder/ScheduleMessages

Imaging Results AvailabilityMessages

Store images imported viaEHR utilities or patient portal into Enterprise Imaging Platform

Communications for viewing imaging exams data and metadata

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rs…

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ADT Messages

Enterprise Viewer(view content standalone or in EHR)

Roth et al. A Foundation for Enterprise Imaging. JDI. 2016.

Enterprise Image Repository, Interface EngineModality Worklist Services

Standards-based Communications (DICOM, Web Services, …)

Standards-based Communications (DICOM, HL7, Web Services, …)

Digital Capture Systems

DICOM Wrap or XDS Import Software

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l HIE

Group #1Native DICOM Image Sources

Group # 2Endoscopes,Microscopes,

In-room Cameras

Group # 3Photography,Video Clips,

Mobile Apps, APIs

Group # 4Image Exchange

Inputs and Outputs

Othe

rs…

. Gateways

EHR

Imaging ProcedureOrder/ScheduleMessages

Imaging Results AvailabilityMessages

Store images imported viaEHR utilities or patient portal into Enterprise Imaging Platform

Communications for viewing imaging exams data and metadata

Othe

rs…

.

ADT Messages

Enterprise Viewer(view content standalone or in EHR)

Roth et al. A Foundation for Enterprise Imaging. JDI. 2016.

Enterprise Image Repository, Interface EngineModality Worklist Services

Standards-based Communications (DICOM, Web Services, …)

Standards-based Communications (DICOM, HL7, Web Services, …)

Digital Capture Systems

DICOM Wrap or XDS Import Software

Ope

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g R

oom

s

Pat

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gy GI

Vid

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es

Othe

rs…

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Med

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nd G

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olog

y

Den

tistry

Uro

logy

Sur

gery

Rad

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n O

ncol

ogy

Loca

l HIE

Group #1Native DICOM Image Sources

Group # 2Endoscopes,Microscopes,

In-room Cameras

Group # 3Photography,Video Clips,

Mobile Apps, APIs

Group # 4Image Exchange

Inputs and Outputs

Othe

rs…

. Gateways

EHR

Imaging ProcedureOrder/ScheduleMessages

Imaging Results AvailabilityMessages

Store images imported viaEHR utilities or patient portal into Enterprise Imaging Platform

Communications for viewing imaging exams data and metadata

Othe

rs…

.

ADT Messages

Enterprise Viewer(view content standalone or in EHR)

Roth et al. A Foundation for Enterprise Imaging. JDI. 2016.

Correct Misperceptionsl Digital Pathology / WSI should:

• be mainstream DICOM source like radiology (not some lame “digital capture” step-child)

• have appropriate specialty-specific viewer accessible throughout the enterprise, not just the Anatomical Pathology department, just like radiology

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DICOM – Enterprise Imaging

Archive

PACS +/- IS

Manager

Standard Boundary Standard Boundary

Camera

Slide Scanner

Modality

Modality Workstations

Analysis Systems

DICOM – Deconstructed PACS

Archive

Manager

Standard Boundary Standard Boundary

Camera

Slide Scanner

Modality

Modality Workstations

Analysis Systems

So what’s the big deal with WSI?l They’re “big”, really big

• not that much bigger than a CT/PET or DBTl DICOM pixel data encoding

• just another multi-frame, color, compressed image

l Multi-frame rather than lots of single frame• as they get larger, run into timeouts during transfer• can’t saturate transport connection with multiple

simultaneous streams

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An illustration of how digital slides are stored in a pyramid structure.

Wang Y, Williamson KE, Kelly PJ, James JA, Hamilton PW (2012) SurfaceSlide: A Multitouch Digital Pathology Platform. PLOS ONE 7(1): e30783. https://doi.org/10.1371/journal.pone.0030783http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0030783

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Baseline Image Tile

Thumbnail Image (low resolution)

Intermediate Zoom Image Tile

Baseline Image (highest resolution)

Intermediate Zoom Image (intermediate resolution)

Retrieved image region

DICOM Supplement 145Aperio, Digital Slides and Third-Party Data Interchange

Per-frame attributes

Pixel data

Shared attributes

Multi-frame v. Single Frame

Per-frame attributes

Pixel data

Shared attributes

Concatenations

Store & Regurgitate Only?

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Scanner Stores DICOM WSI

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Slide Scanner Archive

DICOM

C-STOREor STOW-RS

DICOM WSI to Black Box PACS

Standard Boundary

Slide Scanner

Slide Scanner

Slide Scanner

Slide Scanner

Virtual Microscopy Viewer Queries/Retrieves DICOM WSI

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Slide Scanner Archive

DICOM

C-STORE

Workstation

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Virtual Microscopy Viewer Queries/Retrieves DICOM WSI

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Slide Scanner Archive

DICOM

C-STORE

Workstation

QIDO-RS

Find Images

WADO-RS

Get Metadata

WADO-RS

Get Frames

Virtual Microscopy Viewer Queries/Retrieves DICOM WSI

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Slide Scanner Archive

DICOM

C-STORE

Workstation

QIDO-RS

Find Images

WADO-RS

Get Metadata

WADO-RS

Get Frames

“DICOMweb”“Traditional” DICOM

• HTTP• JSON• XML• JPEG

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DICOM Archive Requirementsl Support WSI Storage SOP Classl Support JPEG baseline and J2K Transfer Syntaxesl Be careful at 2GB and 4GB boundaries (e.g., frame byte offset)l Pay attention to timeoutsl Accept and reassemble concatenationsl Support DICOMweb QIDO-RS and WADO-RS for viewer query,

metadata and frame level retrievall Index pathology-specific metadata for queries

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Summaryl Not all “VNAs” are created equall There is no such thing as a “universal viewer” unless

it incorporates the union of all specialty-specific navigation and visualization paradigms and features

l WSI is just another flavor of DICOM – but the devil is in the details

l There is more to WSI than just creating a DICOM file, the viewer interface and workflow are paramount

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